Best doctors leaving poor nations English-speaking countries benefit from the exodus
New York Times
Oct. 27, 2005

Celia W. Dugger

A new study documents for the first time the devastating exodus of doctors from Africa and the Caribbean to four wealthy English-speaking nations: the United States, Britain, Canada and Australia, which now depend on international medical graduates for a quarter of their physicians. 

The findings are being published today in the New England Journal of Medicine. The study is likely to fuel an already-furious debate about the role the developed world is playing in weakening African public health systems. Pandemics already have shortened life expectancies in some African countries. 

Dr. Agyeman Akosa, director general of Ghana's health service, said in a phone interview from Geneva, where he is attending a World Health Organization forum on the global medical-staffing crisis, that his country's public health system is virtually collapsing because it is losing not just many of its doctors but its best ones. "I have at least nine hospitals that have no doctor at all, and 20 hospitals with only one doctor looking after a whole district of 80,000 to 120,000 people," Akosa said.

 Women in obstructed labor all too often suffer terrible complications or death for lack of an obstetrician, he said. 

The study found that Ghana, with only six doctors for each 100,000 people, has lost three of every 10 doctors it has educated to the United States, Britain, Canada and Australia, each of which has more than 220 doctors per 100,000 people. 

Dr. Fitzhugh Mullan, a professor of medicine and public health at George Washington University, who carried out the study, tapped into databases in the four rich countries to learn where their international medical graduates had come from. 

He said the flight of doctors was less the result of deliberate policies in the wealthy countries than of their failure to train enough doctors to fill their own needs. For example, the United States has about 17,000 medical school graduates each year for 22,000 first-year residency slots. 

"One of the most important things the United States can do for global health, frankly, is to educate more physicians in the United States to work in the United States," he said.

 He described the international market in medical workers as a pecking order with the United States at the pinnacle. In addition to seeking doctors from developing countries, the United States has also netted 8,471 doctors from Canada, 3,360 from Britain and 1,071 from Australia. Those rich countries, in turn, seek doctors from further down the pecking order.

 The biggest losers are the small to medium-size countries of Africa and the Caribbean. Mullan's research found that Jamaica, for example, has lost 41 percent of its doctors and Haiti 35 percent, while Ghana has lost 30 percent and South Africa, Ethiopia and Uganda 14 percent to 19 percent. 

In an editorial that accompanies Mullan's article, Dr. Lincoln C. Chen, director of the Global Equity Center at Harvard, and Dr. Jo Ivey Boufford, a professor of health policy at New York University, call the exodus of publicly trained doctors "a silent theft" by the richest countries from the poorest. 

Crumbling public health systems in poor countries, they wrote, also threaten the health of Americans in the face of potential outbreaks of avian flu and SARS. "Protecting Americans requires viral detection and interdiction at points of origin," they wrote. 

Public health leaders in Africa say they will have to reform their own ailing systems. Dr. Francis Omaswa, who served as director general of Uganda's health service until July, said that half of its doctor positions are vacant and that the exodus is not the only cause. 

For example, he said, some unemployed doctors cannot find jobs because they are not adequately advertised. 

Omaswa, now a special adviser to the World Health Organization on human resources for health, is helping to devise proposals for what African and developed countries can do to ease the staffing crisis. "Africa cannot solve it alone," he said.